Chapter 23

In the meantime the city of Havana was being rendered sanitary in a way which experience had taught would have overcome any bacterial infection, and, in fact, the diseases of filth, such as dysentery, tuberculosis, children's complaints and others, decreased in a surprising manner, while yellow fever seemed to have been little affected if at all.

Evidently, a more thorough overhauling of the matter was necessary to arrive at the truth, and while the question of Sanarelli and his claims was practically put aside, Surgeon-General Sternberg, recognizing the importance of the work before us and that its proportions were such as to render the outcome more satisfactory by the cooperation of several investigators in the same direction, wisely decided to create a board for the purpose and so caused the following to be issued:

Special Orders No. 122 HEADQUARTERS OF THE ARMY, ADJUTANT GENERAL'S OFFICE, WASHINGTON, May 24, 1900

Extract

34. By direction of the Secretary of War, a board of medical officers is appointed to meet at Camp Columbia, Quemados, Cuba, for the purpose of pursuing scientific investigations with reference to the infectious diseases prevalent on the Island of Cuba. Detail for the board:

Major Walter Reed, surgeon, U. S. Army; Acting Assistant Surgeon James Carroll, U. S. Army; Acting Assistant Surgeon Aristides Agramonte, U. S. Army; Acting Assistant Surgeon Jesse W. Lazear, U. S. Army.

The board will act under general instructions to be communicated to Major Reed by the Surgeon General of the Army. By command of MAJOR GENERAL MILES, H. C. CORBIN, Adjutant General

It may be of interest to the reader to learn who these men were and the reasons why they were probably selected for the work.

Major Reed, the first member in the order of appointment, was the ranking officer and therefore the chairman of the board. He was a regular army officer, at the time curator of the Army Medical Museum in Washington and a bacteriologist of some repute. He deservedly enjoyed the full confidence of the surgeon general, besides his personal friendship and regard. Reed was a man of charming personality, honest and above board. Every one who knew him loved him and confided in him. A polished gentleman and a scientist of the highest order, he was peculiarly fitted for the work before him.

Dr. James Carroll, the second member of the board, was a self-made man, having risen from the ranks through his own efforts: while a member of the Army Hospital Corps he studied medicine and subsequently took several courses at Johns Hopkins University in the laboratory branches. At the time of his appointment to the board he had been for several years an able assistant to Major Reed. Personally, Carroll was industrious and of a retiring disposition.

Dr. Jesse W. Lazear was the fourth member of the board. He had graduated from the College of Physicians and Surgeons (Columbia University) in the same class as the writer, in 1892, and had afterwards studied abroad and at Johns Hopkins. Lazear had received special training in the investigation of mosquitoes with reference to malaria and other diseases. Stationed at Columbia Barracks, he had been in Cuba several months before the board was convened, in charge of the hospital laboratory at the camp. A thorough university man, he was the type of the old southern gentleman, kind, affectionate, dignified, with a high sense of honor, a staunch friend and a faithful soldier.

The writer was the third member of the Army Board. Born in Cuba during the ten years' war, while still a child, my father having been killed in battle against the Spanish, I was taken to the United States and educated in the public schools and in the College of the City of New York, graduating from the College of Physicians and Surgeons in 1892. At the breaking out of the war I was assistant bacteriologist in the New York Health Department. The subject of yellow fever research was my chief object from the outset, and, at the time the board was appointed, I was in charge of the laboratory of the Division of Cuba, in Havana.

It may be readily seen from the brief sketch regarding the several members that the components of the yellow-fever board really constituted a perfectly consistent body, for the reason, mainly, that they were all men trained in the special field wherein their labors were to be so fruitful and that before their appointment to the board they had been more or less associated in scientific work.

FIRST PART OF THE WORK OF THE BOARD

My first knowledge of the existence of the board was had through the following letter from my friend Major Reed:

WAR DEPARTMENT, SURGEON GENERAL'S OFFICE, WASHINGTON, May 25, 1900

DR. A. AGRAMONTE, Act'g Asst. Surgeon U. S. A., Military Hospital No. 1, Havana, Cuba

My dear Doctor: An order issued yesterday from the War Department calls for a board of medical officers for the investigation of acute infectious diseases occurring on the Island of Cuba. The board consists of Carroll, yourself, Lazear and the writer. It will be our duty, under verbal instructions from the Surgeon General, to continue the investigation of the causation of yellow fever. The Surgeon General expects us to make use of your laboratory at Military Hospital No. 1 and Lazear's laboratory at Camp Columbia.

According to the present plan, Carroll and I will be quartered at Camp Columbia. We propose to bring with us our microscopes and such other apparatus as may be necessary for the bacteriological and pathological work. If, therefore, you will promptly send me a list of the apparatus on hand in your laboratory, it will serve as a very great help in enabling us to decide as to what we should include in our equipment. Any suggestions that you may have to make will be much appreciated.

Carroll and I expect to leave New York, on transport, between the 15th and 20th of June and are looking forward, with much pleasure, to our association with you and Lazear in this interesting work. As far as I can see we have a year or two of work before us.

Trusting you will let me hear from you promptly, and with best wishes, Sincerely yours, (Signed) WALTER REED

On the afternoon of June 25, 1900, the four officers met for the first time in their new capacity, on the veranda of the officers' quarters at Columbia Barracks Hospital. We were fully appreciative of the trust and aware of the responsibility placed upon us and with a feeling akin to reverence heard the instructions which Major Reed had brought from the surgeon general; they comprised the investigation also of malaria, leprosy and unclassified febrile conditions, and were given with such detail and precision as only a man of General Sternberg's experience and knowledge in such matters could have prepared. After deciding upon the first steps to be taken, it was unanimously agreed that whatever the result of our investigation should turn out to be, it was to be considered as the work of the board as a body, and never as the outcome of any individual effort; that each one of us was to work in harmony with a general plan, though at liberty to carry out his individual methods of research. We were to meet whenever necessary, Drs. Reed, Carroll and Lazear to remain at the Barracks Hospital and I to stay in charge of the laboratory in Havana, at the Military Hospital, where I also had a ward into which yellow-fever cases from the city were often admitted.

Work was begun at once. Fortunately for our purpose, an epidemic of yellow fever existed in the town of Quemados, in close proximity to the military reservation of Camp Columbia. Even before the arrival of Reed and Carroll, Lazear and I had been studying its spread, following the cases very closely; subsequently a few autopsies were made by me, Carroll making cultures from the various tissues and Lazear securing fragments for microscopical examination; a careful record was kept and the results noted; cases gradually became less in number as the epidemic slowly died out, about the middle of August.

In the meantime a rather severe outbreak of yellow fever had occurred in Santa Clara, a city in the interior of the island, having invaded the garrison and caused the death of several soldiers; as the origin of the infection was shrouded in mystery, and cases continued to appear among the troops even after they had moved out of the town, it was agreed that I should endeavor to trace the source of the epidemic and aid the medical authorities in establishing whatever preventive measures might seem proper. This service is here recorded because in the general discussion of the start and course of the epidemic with Dr. J. Hamilton Stone, the officer in charge of the military hospital, we incidentally spoke of the possible agency of insects in spreading the disease, pointing particularly in this direction the fact of the infection of a trooper who, suffering from another complaint, occupied a bed in a ward across the yard from where a yellow fever case had developed two weeks before.

The infection of the city of Santa Clara had evidently taken place from Havana, distant only one night's journey by train. Captain Stone, a particularly able officer, had already instituted effective quarantine measures before my arrival, so that I only remained there a few days.

But as to the actual cause of the disease we were still entirely at sea; it helped us little to know that a man could be infected in Havana, take the train for a town in the interior and start an outbreak there in the course of time.

Upon rejoining my colleagues (July 2) we resumed our routine investigations; not only in Quemados, where the disease was being stamped out, but also in Havana, at "Las Animas" Hospital and at Military Hospital No. 1, where my laboratory (the division laboratory) was located. There was no scarcity of material and the two members who until then had never seen a case of yellow fever (Reed and Carroll) had ample opportunity, and took advantage of it, to become acquainted with the many details of its clinical picture which escape the ordinary practitioner, the knowledge and the appreciation of which, in their relative value, give the right to the title of "expert."

Since the later part of June, reports had been coming to headquarters of an extraordinary increase of sickness among the soldiers stationed at Pinar del Rio, the capital of the extreme western province, and very soon the great mortality from so-called "pernicious malarial fever" attracted the attention of the chief surgeon, Captain A. N. Stark, who, after consulting with Major Reed, ordered me to go there and investigate. A man had died, supposedly from malaria, just before my arrival on the afternoon of July 19. The autopsy which I performed at once showed me that yellow fever had been the cause of his death, and a search through the military hospital wards revealed the existence of several unrecognized cases being treated as malaria; a consultation held with the medical officer in charge showed me his absolute incapacity, as he was under the influence of opium most of the time (he committed suicide several months afterwards), and so I telegraphed the condition of things to headquarters; in answer I received the following:

CHIEF SURGEON'S OFFICE, HDQRS. DEPT. HAVANA AND PINAR DEL RIO, QUEMADOS, CUBA, July 20, 1900

SURGEON AGRAMONTE, Pinar del Rio Barracks, Pinar del Rio, Cuba

Report received last night. My thanks are due for your prompt action and confirmation of my suspicions. STARK, Chief Surgeon

Conditions in the hospital were such as to demand immediate action; the commander of the post refused to believe he had yellow fever among his 900 men and was loath to abandon his comfortable quarters for the tent life in the woods that I earnestly recommended. In answer to my telegram asking for official support, I received the following:

CHIEF SURGEON'S OFFICE, HDQRS. DEPT. HAVANA AND PINAR DEL RIO, QUEMADOS, CUBA, July 21, 1900

SURGEON AGRAMONTE, Pillar del Rio Barracks, Pinar del Rio, Cuba

Take charge of cases. Reed goes on morning train. Wire for anything wanted. Nurses will be sent. Instructions wired commanding officer. Other doctors should not attend cases. Establish strict quarantine at hospital. You will be relieved as soon as an immune can be sent to replace you. Report daily by wire. STARK, Chief Surgeon

When Major Reed came to Pinar del Rio (July 21) I had, the day before, established a separate yellow-fever hospital, under tents, attended by some of the men who had already passed an attack and were thus immune. The Major and I went over the ground very carefully, we studied the sick report for two months back, fruitlessly trying to place the blame upon the first case. I well remember how, as we stood in the men's sleeping quarters, surrounded by a hundred beds, from several of which fatal cases had been removed, we were struck by the fact that the later occupants had not developed the disease. In connection with this, and particularly interesting, was the case of a soldier prisoner who had been confined to the guard-house since June 6; he showed the first symptoms of yellow fever on the twelfth and died on the eighteenth; none of the other eight prisoners in the same cell caught the infection, though one of them continued to sleep in the same bunk previously occupied by his dead comrade. More than this; the three men who handled the clothing and washed the linen of those who had died during the last month were still in perfect health. Here we seemed to be in the presence of the same phenomenon remarked by Captain Stone in reference to his case at Santa Clara, and before that by several investigators of yellow fever epidemics; the infection at a distance, the harmless condition of bedding and clothing of the sick; the possibility that some insect might be concerned in spreading the disease deeply impressed us and Major Reed mentions the circumstance in his later writings. This was really the first time that the mosquito transmission theory was seriously considered by members of the board, and it was decided that, although discredited by the repeated failure of its most ardent supporter, Dr. Carlos J. Finlay, of Havana, to demonstrate it, the matter should be taken up by the board and thoroughly sifted.

The removal of the troops out of Pinar del Rio was the means of at once checking the propagation of the disease.

On the first day of August the board met and after due deliberation determined to investigate mosquitoes in connection with the spread of yellow fever. As Dr. Lazear was the only one of us who had had any experience in mosquito work, Major Reed thought proper that he should take charge of this part of the investigation in the beginning, while we, Carroll and I, continued with the other work on hand, at the same time gradually becoming familiar with the manipulations necessary in dealing with the insects.

A visit was now made to Dr. Finlay, who, much elated at the news that the board was about to investigate his pet theory, the transmission of yellow fever from man to man by mosquitoes, very kindly explained to us many points regarding the life of the one kind he thought most guilty and ended by furnishing us with a number of eggs which, laid by a female mosquito nearly a month before, had remained unhatched on the inside of a half empty bowl of water in his library.

Much to our disappointment and regret, during the first week of August, Major Reed was recalled to Washington that he might, in collaboration with Drs. Vaughan and Shakespeare, complete the report upon "Typhoid Fever in the Army." Thus we were deprived of his able counsel during the first part of the mosquito research. Major Reed was detained longer than he expected and could not return to Cuba until early in October, several days after Lazear's death.

The mosquito eggs obtained from Dr. Finlay hatched out in due time; the insects sent to Washington for their exact classification were declared by Dr. L. O. Howard, entomologist to the Agricultural Department, to be Culex fasciatus. Later, they have been called Stegomyia fasciatus and now go under the name of Stegomyia calopus (Aedes cal.).

Lazear applied some of these mosquitoes to cases of yellow fever at "Las Animas" Hospital, keeping them in separate glass tubes properly labeled, and every thing connected with their bitings was carefully recorded; the original batch soon died and the work was carried on with subsequent generations from the same.

The lack of material at Quemados caused us to remove our field of action to Havana, where cases of yellow fever continued to appear. We met almost every day at "Las Animas" Hospital, where Lazear was trying to infect his mosquitoes, or now and then I performed autopsy upon a case, and Carroll secured sufficient cultures to last him for several days of bacteriological investigation.

Considering that, in case our surmise as to the insect's action should prove to be correct, it was dangerous to introduce infected mosquitoes amongst a population of 1,400 non-immunes at Camp Columbia, Dr. Lazear thought best to keep his presumably infected insects in my laboratory at the Military Hospital No. 1, from where he carried them back and forth to the patients who were periodically bitten.

Incidentally, after the mosquitoes fed upon the yellow fever patients, they were applied, at intervals of two or three days, to whoever would consent to run the risk of contracting yellow fever in this way; needless to say, current opinion was against this probability and as time passed and numerous individuals who had been bitten by insects which had previously fed upon yellow fever blood remained unaffected, I must confess that even the members of the board, who were rather sanguine in their expectations, became somewhat discouraged and their faith in success very much shaken.

No secret was made of our attempts to infect mosquitoes; in fact many local physicians became intensely interested, and Lazear and his tubes were the subject of much comment on the part of the Havana doctors, who nearly twenty years before had watched and laughed at Dr. Finlay, then bent apparently upon the same quest in which we were now engaged. Dr. Finlay himself was somewhat chagrined when he learned of our failure to infect any one with mosquitoes, but, like a true believer, was inclined to attribute this negative result more to some defect in our technique than to any flaw in his favorite theory.

Although the board had thought proper to run the same risks, if any, as those who willingly and knowingly subjected themselves to the bites of the supposedly infected insects, opportunity did not offer itself readily, since Major Reed was away in Washington and Carroll, at Camp Columbia, engrossed in his bacteriological investigations came to Havana only when an autopsy was on hand or a particularly interesting case came up for study. I was considered an immune, a fact that I would not like to have tested, for though born in the island of Cuba, I had practically lived all my life away from a yellow fever zone; it was therefore presumed that I ran no risk in allowing mosquitoes to bite me, as I frequently did, just to feed them blood, whether they had previously sucked from yellow fever cases or not. And so, time passed and several Americans and Spaniards had subjected themselves in a sporting mood to be bitten by the infected (?) mosquitoes without causing any untoward results, when Lazear applied to himself (August 16, 1900) a mosquito which ten days before had fed upon a mild case of yellow fever in the fifth day of his disease; the fact that no infection resulted, for Lazear continued in excellent health for a space of time far beyond the usual period of incubation, served to discredit the mosquito theory in the opinion of the investigators to a degree almost beyond redemption, and the most enthusiastic, Dr. Lazear himself, was almost ready to "throw up the sponge."

I had as laboratory attendant a young American, a private belonging to the Hospital Corps of the Army, who more than once had bared his arm to allow a weak mosquito a fair meal with which to regain its apparently waning strength; Loud, for that was his name, derided the idea that such a little beast could do so much harm as we seemed ready to accuse it of, although he was familiar with the destruction caused by bacteria, but then, he used to say, "bacterial work in armies of more than a million bugs at the same time and no one would be d---- fool enough to let more than one or two gnats sting him at once."

This state of things, the gradual loss of faith in the danger which mosquitoes seemed to possess, led Dr. Lazear to relax a little and become less scrupulous in his care of the insects, and often, after applying them to patients, if pressed for time, he would take them away with him to his laboratory at Columbia Barracks, where, the season being then quite warm, they could be kept as comfortably as at the Military Hospital laboratory. Thus it happened that on the twenty-seventh of August he had spent the whole morning at "Las Animas" Hospital getting his mosquitoes to take yellow-fever blood: the procedure was very simple; each insect was contained in a glass tube covered by a wad of cotton, the same as is done with bacterial cultures. As the mouth of the tube is turned downwards, the insect usually flies towards the bottom of the tube (upwards), then the latter is uncovered rapidly and the open mouth placed upon the forearm or the abdomen of the patient; after a few moments the mosquito drops upon the skin and if hungry will immediately start operations; when full, by gently shaking the tube, the insect is made to fly upwards again and the cotton plug replaced without difficulty. It so happened that this rather tedious work, on the day above mentioned, lasted until nearly the noon hour, so that Lazear, instead of leaving the tubes at the Military Hospital, took them all with him to Camp Columbia: among them was one insect that for some reason or other had failed to take blood when offered to it at "Las Animas" Hospital.

This mosquito had been hatched in the laboratory and in due time fed upon yellow-fever blood from a severe case on August 15, that is, twelve days before, the patient then being in the second day of his illness; also at three other times, six days, four days and two days before. Of course, at the time, no particular attention had been drawn to this insect, except that it refused to suck blood when tempted that morning.

After luncheon that day, as Carroll and Lazear were in the laboratory attending to their respective work, the conversation turning upon the mosquitoes and their apparent harmlessness, Lazear remarked how one of them had failed to take blood, at which Carroll thought that he might try to feed it, as otherwise it was liable to die before next day (the insect seemed weak and tired); the tube was carefully held first by Lazear and then by Carroll himself, for a considerable length of time, upon his forearm, before the mosquito decided to introduce its proboscis.

This insect was again fed from a yellow fever case at "Las Animas" Hospital on the twenty-ninth, two days later, Dr. Carroll being present, though not feeling very well, as it was afterwards ascertained.